Provider Demographics
NPI:1093051484
Name:DRAKE, DOUGLAS
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2430
Mailing Address - Country:US
Mailing Address - Phone:815-397-4327
Mailing Address - Fax:815-397-4341
Practice Address - Street 1:5910 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2430
Practice Address - Country:US
Practice Address - Phone:815-397-4327
Practice Address - Fax:815-397-4341
Is Sole Proprietor?:No
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2497237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist